2.0 Analysis 2.1 Loading, Trim and Stability Analysis Compliance with the minimum stability criteria of STAB 4 ensures that small fishing vessels maintain what are generally recognized as adequate margins of intact transverse stability throughout a range of standard loading conditions related to the vessel's intended service. The regulatory criteria are such that the margin of intact stability they provide ensures that the vessel is able to withstand and recover from severe weather an other detrimental influences generally to be expected in routine operation. The standard loading conditions incorporate stores, spares, consumables and fish catch loads and configurations envisaged during a typical voyage, and provide a basis for the assessment of the many other combinations that may be adopted in service. However, compliance with the stability criteria does not ensure immunity against capsizing regardless of the circumstances. It is the master's responsibility to exercise prudence and good seamanship to ensure that the vessel's watertight integrity and adequate stability are maintained at all times. Furthermore, it is the responsibility of the owners to ensure the stability data submitted for approval accurately reflect the vessel's loading conditions and modes of operation. The trim and stability data submitted for approval were comprised of loading conditions specifically related to herring packing operations when the vessel was not outfitted with trawl nets, trawl fishing doors and spare fishing gear. At the time of the occurrence the PACIFIC CHARMER was engaged in catching herring and her stability characteristics were detrimentally affected by the additional weight of fishing gear located above and at the after end of the main deck. This additional weight raised the vessel's inherent centre of gravity. Furthermore, the effective freeboard, trim, and intact stability were also adversely affected by the carriage of additional and spare fishing gear in the lazaret and on the main deck, forecastle deck rails and wheel-house top. On departure, the freeboard and trim of the PACIFIC CHARMER were considered normal, undeserving of comment, and consistent with an after trim of 0.38 m (15 in) that would have resulted from the forepeak tank being filled with water ballast. None of the survivors recalls any additional ballasting or de-ballasting operations during the voyage. Consequently, it is considered most likely that the forepeak ballast tank was full on departure and remained full throughout the voyage. The primary function of the seawater ballast was to maintain acceptable working trim levels; however, such a ballast configuration also resulted in a slight reduction of the vessel's transverse stability characteristics. As the voyage progressed and the herring catch was taken on board, the effective freeboard was gradually reduced. The transverse stability was subject to fluctuation because of the free surface effects of partially full fuel and service tanks, fish holds, and variations in the weight and extent of fish and water retained on the main deck. In general, few fishermen fully understand free surface effect and fewer appreciate the substantial reduction of initial transverse stability that results when water, even a few centimetres deep, is shipped and retained on deck. When this effect is coupled with the significant loss of effective water plane area when the deck edge becomes submerged, the sudden reduction in transverse stability can be disastrous. Furthermore, intact transverse stability calculations are based on the ideal level sea state, while dynamic influences related to actual sea-going conditions and loading configurations cause the effective reserve stability to fluctuate, such that initial roll angles are usually greater than those calculated by static methods. While in the highly vulnerable and fluctuating condition indicated by the calculated stability characteristics, the PACIFIC CHARMER was suddenly subjected to the detrimental dynamic effects of the suspended weight of the cod-end and of all the slack liquids and fish as they flowed to starboard. Additionally, the centrifugal forces generated while the vessel was turning to port induced a slight heel to starboard and a further transfer of heeling energy to the hull, slack fish and liquids such that they combined and contributed to the dynamic effects that overcame the vessel's initial stability and initiated the gradual heeling; heeling from which she was unable to recover. The unexpected gradual heeling to starboard, and inability to recover, are typical of the behaviour sequence associated with a marked reduction of initial transverse stability due to extensive free surface effects which--in conjunction with concurrent, sudden dynamic heeling forces--often results in severe heeling or capsizing. Such a scenario, together with the subsequent downflooding that ultimately caused the sinking, is consistent with the sequence of events reported by the survivors who were on board the PACIFIC CHARMER at the time of her loss. 2.2 Fisheries Management Regime The DFO's Fisheries Management Plan for 1997 allowed for a food and bait herring fishery quota of 650 short tons. The total number of small fishing vessels participating in the food and bait herring fishery was restricted and the selection of individual vessels was decided by competition in a controlled lottery. The 1997 conditions for commercial fishing licences for herring, pursuant to the Fishery (General) Regulations, indicated that a licensed vessel was allowed a maximum catch of 50 short tons. If that total were exceeded, the master should deliver the excess catch to another vessel licensed for the same area and the herring so transferred would be assessed as part of the catch of the receiving vessel. Individual licence holders can choose from a list of recognized observers that is issued by the DFO. The DFO does not consider it a conflict of interest if the observer is also an employee of the licence holder, as was the case with the PACIFIC CHARMER and the ARCTIC OCEAN. The Food and Bait Fishery Management Plan 1997, issued by the DFO Director General, Pacific Region and promulgated to the fishing industry states,in part: . . . in 1997, only vessels that are fully equipped and fully crewed and capable of catching, pumping and packing their own catches will be allowed entry into the draw. This lottery system will prevent vessels that are not equipped to catch and handle herring properly from entering this fishery. .. . One intent of the management plan was to ensure that only bona fide small herring catching vessels would participate in the food and bait herring fishery lottery. However, the plan did not specifically require confirmation of compliance with the stability requirements of the Small Fishing Vessel Regulations for vessels catching herring, nor did the plan require verification of operator certification on the individual participating vessels. 2.3 Search and Rescue 2.3.1 Time of Sinking The rapidity of the sinking precluded transmission of a MAYDAY distress call by VHF radio; however, the time of the occurrence can be determined, with some accuracy, from other sources. At the time of the sinking the positions of the available orbiting and geostationary satellites were such that the EPIRB distress signal from thefirst in-range satellite was received by CMCC, in Trenton, at 0132. Such recorded signal information, in conjunction with the time shown on the stopped electric clock in the wheel-house, would indicate that the sinking occurred shortly before 0130. 2.3.2 Occurrence Location and SAR Response EPIRB-initiated detection of marine emergencies, by CMCC, and subsequent SAR response, is achieved by the monitoring and receipt of emergency signals from two distinct earth satellite systems. One system is comprised of high-altitude geostationary environmental satellites, while the COSPAS-SARSAT system is comprised of lower altitude, polar-orbiting satellites. The geostationary environmental satellites are not dedicated SAR units; however, their high altitude and large coverage of the earth's surface allow them early detection of EPIRB 406 MHz emergency signals. While they do not provide a precise location of the source of the signal, (unless it is an EPIRB with GPS) they do enable each particular EPIRB to be identified by reference to registered EPIRB ownership records. These records contain EPIRB owners' names and location information, which facilitate early telephone contact and confirmation of the vessel's name and most-recent operating location. The COSPAS-SARSAT system is comprised of a number of lower altitude, polar-orbiting satellites making complete and continuous orbits of the earth in approximately 100 minutes. One function of this system is the detection of EPIRB 121.5 MHz emergency signals for marine SAR purposes. The detection of EPIRB emergency signals and determination of an accurate occurrence location depend on the relative positions of the COSPAS-SARSAT orbiting satellites at the particular time. CMCC and RCC experience over several years of operation shows that from receipt of an EPIRB emergency transmission the average time required to calculate and establish an accurate occurrence location is some 42 minutes. Owners of early (and many current) models of EPIRBs are often unaware of the inherent limitations of these models. However, EPIRBs utilizing a GPS feed in their transmitted signals are now available. These EPIRBs ensure that an accurate occurrence position can be determined immediately upon receipt of the initial emergency transmission. Such EPIRBs enable SAR services to be speedily tasked and deployed. The EPIRB on board the PACIFIC CHARMER had no GPS facility; however, the initial detection of its 406 MHz emergency signal by CMCC at 0132, together with the subsequent receipt of its 121.5 MHz signals from the COSPAS-SARSAT satellites and the corroborative information from the owners, resulted in vessel identification and a fairly accurate occurrence location by 0152. The acquisition of all this information was within some 20 minutes of detection of the initial geostationary environmental satellite emergency signal by CMCC. Initiation of the primary SAR response by RCC Victoria began with the tasking of the SAR hovercraft at 0155, some 16 minutes after receipt of the faxed information from CMCC at 0139. Both of these elapsed times were significantly less than the established average time of 42 minutes. The final approach and on-scene search time were significantly reduced because the SAR hovercraft was able to home on the 121.5 MHz signal and quickly recover the DFO observer holding the EPIRB and the two crew members nearby before they succumbed to the effects of hypothermia. From the time of the abandonment of the vessel just prior to 0130 until the recovery of the survivors shortly after the arrival of the SAR hovercraft at 0303, the survivors were in seawater of 6.6C for slightly more than one and a half hours. Scientific studies of cooling rates on average adults (wearing standard lifejackets and light clothing, in such conditions) show that while they would be significantly weakened and barely able to help themselves when rescued, there is a strong possibility of survival if recovered. Such was the case with the three survivors in this instance. 3.0 Conclusions 3.1 Findings The data in the vessel's approved Trim and Stability Booklet was related to herring packing operations only, with the fish holds pre-filled with seawater. Intact stability data incorporating the weights of fishing nets, trawl doors and other gear necessary when catching herring were not submitted bythe owners for approval, as required by the Small Fishing Vessel Inspection Regulations. The approved trim and stability data available for the guidance of the master did not represent the vessel's actual status when rigged and outfitted for catching herring. The conditions of eligibility for entry in the vessel selection lottery process of the DFO 1997 Food and Bait Fish Management Plan were not related to compliance with the stability requirements of the Small Fishing Vessel Regulations for vessels engaged in catching herring, nor did the conditions require verification of the certification of the operators of the selected vessels. The cumulative weight of trawl fishing equipment and the additional gear stowed in the lazaret, on the wheel-house top and lashed to the forecastle deck side railings, raised the vessel's centre of gravity and detrimentally affected the vessel's intact stability characteristics. The weathertight doors from the main deck to the accommodation area and the engine-room were secured in the open position, compromising the watertight integrity of the vessel. This allowed shipped seawater to downflood into the hull. A fish-loading manhole in the fish hold hatch coaming was open, which allowed shipped water to downflood into the starboard-side, aftermost fish hold. The watertight door to the lazaret was secured in the open position by a length of synthetic rope and this contributed to the extent of the under-deck flooding. Transverse stability was reduced, and subject to fluctuation, due to the free surface effects of partially full fish holds and fuel tanks, and the varying quantities of fish and drain water retained on the main deck while the catch was being stowed. The cumulative dynamic effects of the cod-end (while it was partially suspended), the centrifugal effects on the hull while the vessel was turning, and the slack liquids on deck and in the holds suddenly reduced transverse stability and initiated heeling to starboard. When the vessel heeled to starboard, the vessel's recovery was prevented when seawater, shipped and retained on the main deck, downflooded into the engine-room and after fish hold and gravitated to starboard. Under-deck flooding accumulated in the engine-room and shaft tunnel, progressed into the lazaret and continued until reserve buoyancy was lost and the vessel sank. The initial large angle of heel and rapidity of the sinking precluded transmission of a MAYDAY distress message, successful deployment of either of the two inflatable liferafts, or the donning of personal life-saving equipment by the crew. The 406MHz signal from the automatically activated EPIRB was detected by CMCC Trenton at 0132. The owners' identity and contact information, obtained from registered EPIRB records, was faxed to RCC Victoria at 0139. The occurrence location and EPIRB identification derived from EPIRB 406 MHz signals detected by CMCC and relayed to RCC at 0152, were subsequently corroborated by the vessel's owners, by telephone. The identity and location of the PACIFIC CHARMER were determined within some 20 minutes of the initial emergency signal being detected at CMCC Trenton. The primary SAR response was initiated by RCC Victoria within 16 minutes of receipt of the emergency signal information faxed by CMCC Trenton at 0139. The CCG SAR hovercraft rescued three of the persons who had been on board the PACIFIC CHARMER. The bodies of the master and one crew member, who had succumbed to the effects hypothermia and drowned, were subsequently located, recovered and transported to shore. Fixed and rotary-wing aircraft from the USCG and 442 Squadron, together with CCG vessels, CCG Auxiliary units, and commercial and other private vessels, responded promptly and participated in the search operations. 3.2 Causes The vessel initially heeled to starboard because her intact transverse stability had been reduced by the cumulative detrimental effects of the weight of additional and spare fishing gear; asymmetric loading; free surface effects of liquids in partially filled tanks and fish holds; and fish waste water retained on deck. The dynamic effects of the weight of the trawl net cod-end being briefly suspended from a winch located above the wheel-house caused a sudden rise of the vessel's virtual centre of gravity. In conjunction with the initial small heel to starboard, the dynamic effects were such that the vessel heeled further to starboard and remained briefly at an angle of about 40 degrees. Seawater shipped at this time downflooded through open weathertight doorways until all reserve buoyancy was lost and the PACIFIC CHARMER sank. 4.0 Safety Action 4.1 Action Taken 4.1.1 Watertight Integrity and Downflooding In February 1998 a Marine Safety Information letter (MSI #02/98) was sent by the Transportation Safety Board to the owners of the vessel, with a copy to TC. The letter raised concern regarding the watertight doors being lashed open, allowing for rapid downflooding and the subsequent loss of stability of the PACIFIC CHARMER. The letter also raised concerns about added weight, over and above the weight allowance used to prepare the trim and stability booklet. In response, TC indicated that their Marine Safety Branch in Vancouver contacted the owners of the vessel and her near-sister ship ARCTIC OCEAN with regard to the preparation and submission of additional stability data. In April 1998 TC issued a Ship Safety Bulletin (SSB #06/98) entitled Responsibilities of Shipowners and Masters Respecting Maintenance of Weathertight Integrity of their Vessels. The bulletin reminds shipowners and masters of all classes of ships of the paramount importance of maintaining the weathertight integrity of a ship at all times. The SSB urges the masters to ensure that doors, hatches, manholes, deadlights and all closing appliances are closed tight immediately after use, and maintained closed in bad weather. The PACIFIC CHARMER changed ownership and is now named the PACIFIC COASTER; the new owner does not intend to re-employ her as a fishing vessel. 4.1.2 Stability Requirements Following the occurrence, the ARCTIC OCEAN was subjected to an inclining experiment. The report--and related trim and stability loading conditions when catching herring--were submitted to TC for approval. The Trim and Stability Booklet of the ARCTIC OCEAN, with all of the required operational conditions duly reflecting the actual operations of the vessel, was approved on 10 June 1999. The DFO also revised the entry conditions for future vessel-selection lotteries. Changes include stability requirements for small fishing vessels engaged in catching herring. The entry conditions also incorporate requirements regarding the certification of vessel operators.